Brief Intervention for Anxiety in Primary Care Patients

Abstract

This article addresses the difficulty of assessing and managing multiple anxiety disorders in the primary care setting, by providing a simple, easy-to-learn, unified approach to the diagnosis, and care management of the 4 most common anxiety disorders found in primary care: panic, generalized anxiety disorders, social anxiety disorders, and posttraumatic stress disorder. This evidence-based approach was developed for an ongoing National Institute of Mental Health-funded study designed to improve the delivery of evidence-based medication and psychotherapy treatment to primary care patients with these anxiety disorders. We present a simple, validated method to screen for the 4 major disorders that emphasizes identifying other medical or psychiatric comorbidities that can complicate treatment; an approach for initial education of the patient and discussion about treatment, including provision of some simple cognitive behavioral therapy skills, based on motivational interviewing/brief intervention approaches previously used for substance use disorders… (and more not included in this summary).

Introduction

In any given year, 18% of people will suffer from an anxiety disorder. The majority of these individuals receive treatment in general medical rather than specialty mental health settings. Anxiety disorders are as disabling as depressive disorders and generate increased costs because the physical manifestations of anxiety often prompt expensive diagnostic procedures. In primary care, only a small minority of anxious patients receive treatment targeting their anxiety.

Studies suggest that the poor quality of care for anxiety in primary care may be related to difficulty recognizing and diagnosing anxiety disorders, the increased time and enhanced skill needed to optimally engage such patients in care, and a low perceived need for psychiatric treatment among patients. However, an even greater barrier to the effective delivery of evidence-based care for anxiety is the nonunitary nature of anxiety disorders: instead of having one depressive disorder (major depression) to diagnose and treat, primary care physicians are faced with multiple anxiety disorders (eg, panic disorder [PD], generalized anxiety disorder [GAD], social anxiety disorder [SAD], and posttraumatic stress disorder [PTSD]). This multiplicity of disorders makes it hard to have any unitary traction for public health education efforts; physicians must remember 4 different diagnostic and treatment approaches and, with the multitude of other problems they manage, this array of diagnostic algorithms and treatment options can become quite daunting.

This article provides a unified approach to the diagnosis, care management, and pharmacotherapy of primary care anxiety. We focus on the 4 most common anxiety disorders, all of which have an annual prevalence in primary care of between 5% and 10%, and cumulative rates for any of these between 10% and 15%. We developed this simple, easy-to-learn approach as part of an ongoing National Institute of Mental Health-funded study designed to improve the delivery of evidence-based medication and psychotherapy treatment to primary care patients with these anxiety disorders.

We present a simple, validated method to screen for the 4 major disorders. The method emphasizes the identification of other medical or psychiatric comorbidities that can complicate treatment; an approach for the initial education of the patient and discussion about treatment based on motivational interviewing/brief intervention approaches previously used for substance use disorders.

Screening and Assessment

The assessment should determine which anxiety disorders are present; what other conditions (eg, depression, substance abuse, or pain) accompany it; which treatments have been tried in the past; and what the patient expects of treatment. Although performing a comprehensive diagnostic interview is not practical, asking a single question about each of the 4 common anxiety disorders is simple, quick, and sensitive. Asking 2 simple questions about mood and anhedonia to check for depression (a positive answer to either suggests major depression) may be as effective as using longer instruments. The 3-item Alcohol Use Disorders Identification Test-C is highly sensitive for problem alcohol use, with cutoff scores of 6 for men and 4 for women indicating problem use, and a single 0 to 10 analog item asking about pain has been previously validated. This brief screening battery (Appendix 1) will suggest how many of the 4 anxiety disorders are present and if major depression, problem alcohol use, or chronic pain are also issues. Patients screening positive for panic attacks might have them cued by social situations (SAD) or traumatic memories (PTSD), so a follow-up question about whether they occur when the patient is alone and if they were unexpected can be useful in clarifying whether PD is present.

All anxious patients, whether or not they also have depression, should be assessed for current thoughts of active self-harm, passive thoughts of being "better off dead," and a history of suicide attempts. Ask patients with suicidal thoughts whether they have a plan, access to means (ie, firearms or stockpiled medications), or "reasons for living" that would stop them from acting. Caution them that substance abuse increases risk for suicide. Patients unable to both contract for safety and agree to a specific safety plan should be referred to mental health professionals for evaluation.

A patient who has failed to respond to several antidepressants and has a mixture of anxiety and depressive symptoms could be suffering from an unrecognized bipolar illness. [25] Such patients may also complain of overstimulation with antidepressants and may report brief positive responses to these agents that rapidly wane. This is a difficult diagnosis to make because it often requires multiple observations over a period of time to confirm retrospective reports of mood fluctuations. Patients endorsing fewer than 7 of 13 yes/no items on the Mood Disorder Questionnaire are highly unlikely to have bipolar illness, but scores higher than 7 detect fewer than half the cases. Hence, consultation with a psychiatrist is usually the most prudent option.

Anxiety severity can be measured with the GAD-7 scale, modeled after the now familiar Patient Health Questionnaire-9 scale for depression. A score above 10 suggests anxiety severity sufficient enough to consider treatment. Although this scale contains 6 GAD items and one PD-specific item, patients with other anxiety disorders also score high on this (see the scale at http://www.healthandage.com/public/health-center/7/article/3308/gm=20!gid2=3129). For measurement of functional impairment caused by anxiety, the 5-item Overall Anxiety Severity and Impairment Scale(OASIS) is ideal. Iin addition to the frequency and intensity of anxiety it measures the degree of avoidance and interference with work and social function, and has a cutoff score of 8 for clinically significant anxiety (see Appendix 2). Once done at baseline, these scales should be used to monitor treatment outcomes on subsequent visits because multiple studies show that outcome improves with ongoing monitoring of treatment. [32,33]

Ask patients whether they have had medication or psychotherapy treatment in the past for their anxiety and how helpful it has been. Because there are no standardized scales to determine this, ask whether a treatment has helped a little, moderately, or a lot (ie, returned them to their prior state). These questions correspond to frequently used measures in medication trials of "partial response" (25% improvement), "response" (50% improvement), and remission (75% to 100% improvement). [34] It is also important to know if treatment was stopped because of side effects and the nature of these. This is critical for anticipating problems with adherence. Finally, ask 2 simple questions about how much, on a scale of 0 (none) to 10 (definitely), the patient thinks treatment might work ("outcome expectancy") and how confident they are they can help the treatment along (self-efficacy expectancy). Both of these measures are powerful determinants of whether patients remain in treatment and whether they improve. If any problems with treatment adherence arise, these measures can be used productively in a follow-up counseling session with the physician or non-MD team members, using the motivational interviewing approach outlined below.

Managing the Initial Visit: A Brief Intervention

The goal of an initial visit is to establish an empathic working relationship by using motivational interviewing techniques and style; to give the patient feedback about their problem (what are the likely disorders and how does their anxiety severity fit in with population norms [based on GAD-7 norms]); to understand the patient's motivation for treatment; and to review possible barriers to treatment, whether psychological, social, or logistic. Once the patient is interested in pursuing treatment, the physician must help the patient see that making specific changes in behavior and thinking will speed improvement before prescribing medication. This state of "self-activation" can frame the medication treatment, improving its efficacy and the patient's adherence to it.

Avoiding an authoritarian and prescriptive approach with the anxious patient is essential because such a style inadvertently encourages repeated reassurance seeking and discourages self-activation; instead, the style is a blend of "supportive companion" and "knowledgeable consultant." It is best to reflect how the anxiety has adversely affected them (the "negatives" of being anxious) and help them to overcome whatever barriers might interfere with their pursuit of treatment (eg, logistic problems, concerns about taking medication, belief that treatment will not work). If the patient has low expectations that treatment will work (low "outcome expectancy") or that they can do much to help it along (poor "self-efficacy expectancy"), ask what might improve these expectancies and reinforce whatever strengths they have (eg, perseverance). Avoid arguing (roll with any resistance the patient shows), [41] and instead help the patient develop an awareness of the discrepancy between where they are (all the "negatives" that go with anxiety) and where they would like to be (all the "positives" that go with being anxiety free, what they would be able to do, etc). Some patients may not want to commit during an initial session, but laying the groundwork could make a repeat visit much easier. Available web sites detail this interviewing approach ( http://motivationalinterview.org/training/index.html#training), which has been shown to enhance adherence and participation for psychiatric and medical disorders. Although best known for use in substance abuse treatment, there is increasing interest in using these techniques with anxiety disorders and evidence that it may increase efficacy and retention in cognitive behavioral treatment (CBT). Conceptualizing anxiety as a "behavior" (ie, it ultimately can be under a patient's control) rather than a "symptom" makes it easier to apply this approach. Avoidance is the major driver of all anxiety, fuels failures of motivation and self-activation, and promotes maladaptive coping strategies. Patients need to be gently encouraged to face their fears by decreasing avoidant behavior and adopting a more activated life approach. By describing these behaviors as what successful people do to get over anxiety, greater self-activation will become more attractive to the patient.

Providing Education and Simple Skills for Anxiety

Use this part of the session to frame medication treatment. For patients ambivalent about treatment, try this by itself and revisit the possibility of medication in a second visit. Educate patients about the "cycle of anxiety" (see Figure 1), which consists of a positive feedback cycle where anxious thoughts, physical symptoms, and avoidance behavior feed on one another and aggravate anxiety. Use the figure to illustrate that genetic vulnerability, stressful experiences, and maladaptive thoughts and habits all contribute to anxiety and hence both medications and habit change can be therapeutic. Understanding that anxiety is a normal human response that the patient is having trouble turning off when it is not needed helps normalize the reaction.

Figure 1.  Cycle of anxiety.

CBT approaches are used to interrupt this cycle and typically require at least 6 to 8 sessions. Although it has not been formally investigated, introducing these CBT principles into the primary care visit could be effective; previous studies have found a single educational session can be beneficial. [45] Here we provide some simple educational guidelines that address the behavioral, cognitive, and physical manifestations of anxiety and are discussed in more detail in standard textbooks.

Behavioral avoidance can be directly counteracted by gradual exposure to feared objects or situations. Encourage the patient to make a list of their most feared situations (from least feared to most feared) and suggest they gradually try to face these situations, starting with the easiest first (eg, social situations for SAD, reminders of trauma for PTSD, situations from which it is difficult to escape or help is not readily available for PD, and situations involving more self-reliance, for example, for GAD). If they take to this, it could well require 8 to 12 weeks to work through least feared to most feared. The most important point is for practice to be regular and daily with little interruption.

During exposure, cognitive distortions are likely to arise and need to be questioned with an open scientific mind. The 2 most common errors made by anxious patients are overestimating the risk that something bad will happen (jumping to conclusions, eg, "if I feel lightheaded, I will faint") or thinking that if something bad does happen the outcome will be terribly catastrophic (blowing things out of proportion, eg, "I will panic while driving and will lose control of the car and crash"). Help patients understand that these thinking patterns are unrealistic (ie, these beliefs have rarely, if ever, been confirmed in real life) so they can develop more evidence-based appraisals. Some patients may be able to apply these simple principles themselves although many others are likely to need more coaching, which could be provided in brief follow-up sessions or through referral to a CBT expert.

Finally, physical symptoms of anxiety can be counteracted by relaxation techniques such as progressive muscle relaxation and diaphragmatic breathing (put one hand on your belly, the other on your chest, and make only the hand on your belly move when you breathe; this should be practiced several times a day). Regular exercise also contributes to counteracting physical symptoms of anxiety, as will avoidance of caffeine and alcohol and poor sleep hygiene, which can often aggravate anxiety. Addressing these lifestyle factors can often have a clear-cut effect. Finally, emphasize to patients that they do not need to totally eliminate anxious symptoms. Instead, they should develop an attitude that symptoms can be managed and even tolerated while they do something they were not able to do previously (eg, drive on the freeway). This helps establish realistic expectations about treatment.

-Excerpted from “Brief Intervention for Anxiety in Primary Care Patients” Peter Roy-Byrne, MD; Jason P. Veitengruber, MD; Alexander Bystritsky, MD; Mark J. Edlund, MD, PhD; Greer Sullivan, MD; Michelle G. Craske, PhD; Stacy Shaw Welch, PhD; Raphael Rose, PhD; Murray B. Stein, MD, Journal of the American Board of Family Medicine. From Medscape.com, published: 06/17/2009, http://www.medscape.com/viewarticle/589932 retrieved 6/24/09.

 

Appendix 1

Anxiety: "Have you ..."

Depression: "Over the past 2 weeks, have you ..."

Alcohol Problems:

"In the past year ... "

0

1

2

3

4

1) How often did you have a drink containing alcohol?

Never

Monthly or less

2-4 times a month

2-3 times a week

≥4 times a week

2) How many drinks containing alcohol did you have on a typical day when you were drinking?

1 or 2

3 or 4

5 or 6

7-9

≥10

N/A (If #1 = 0)

3) How often did you have 6 or more (≥4 for women) drinks on one occasion?

Never

Less than monthly

Monthly

Weekly

Daily or almost daily

N/A (If #1 = 0)

Pain:

 

Appendix 2:

Overall Anxiety Severity and Impairment Scale (OASIS)

1. In the past week, how often have you felt anxious?

0 = No anxiety in the past week.
1 = Infrequent anxiety. Felt anxious a few times.
2 = Occasional anxiety. Felt anxious as much of the time as not. It was hard to relax.
3 = Frequent anxiety. Felt anxious most of the time. It was very difficult to relax.
4 = Constant anxiety. Felt anxious all of the time and never really relaxed.

2. In the past week, when you have felt anxious, how intense or severe was your anxiety?

0 = Little or none. Anxiety was absent or barely noticeable.
1 = Mild. Anxiety was at a low level. It was possible to relax when I tried. Physical symptoms were only slightly uncomfortable.
2 = Moderate. Anxiety was distressing at times. It was hard to relax or concentrate, but I could do it if I tried. Physical symptoms were uncomfortable.
3 = Severe. Anxiety was intense much of the time. It was very difficult to relax or focus on anything else. Physical symptoms were extremely uncomfortable.
4 = Extreme. Anxiety was overwhelming. It was impossible to relax at all. Physical symptoms were unbearable.

3. In the past week, how often did you avoid situations, places, objects, or activities because of anxiety or fear?

0 = None. I do not avoid places, situations, activities, or things because of fear.
1 = Infrequent. I avoid something once in a while, but will usually face the situation or confront the object. My lifestyle is not affected.
2 = Occasional. I have some fear of certain situations, places, or objects, but it is still manageable. My lifestyle has only changed in minor ways. I always or almost always avoid the things I fear when I’m alone, but can handle them if someone comes with me.
3 = Frequent. I have considerable fear and really try to avoid the things that frighten me. I have made significant changes in my life style to avoid the object, situation, activity, or place.
4 = All the Time. Avoiding objects, situations, activities, or places has taken over my life. My lifestyle has been extensively affected and I no longer do things that I used to enjoy.

4. In the past week, how much did your anxiety interfere with your ability to do the things you needed to do at work, at school, or at home?

0 = None. No interference at work/home/school from anxiety.
1 = Mild. My anxiety has caused some interference at work/home/school. Things are more difficult, but everything that needs to be done is still getting done.
2 = Moderate. My anxiety definitely interferes with tasks. Most things are still getting done, but few things are being done as well as in the past.
3 = Severe. My anxiety has really changed my ability to get things done. Some tasks are still being done, but many things are not. My performance has definitely suffered.
4 = Extreme. My anxiety has become incapacitating. I am unable to complete tasks and have had to leave school, have quit or been fired from my job, or have been unable to complete tasks at home and have faced consequences like bill collectors, eviction, etc.

5. In the past week, how much has anxiety interfered with your social life and relationships?

0 = None. My anxiety doesn’t affect my relationships.
1 = Mild. My anxiety slightly interferes with my relationships. Some of my friendships and other relationships have suffered, but, overall, my social life is still fulfilling.
2 = Moderate. I have experienced some interference with my social life, but I still have a few close relationships. I don’t spend as much time with others as in the past, but I still socialize sometimes.
3 = Severe. My friendships and other relationships have suffered a lot because of anxiety. I do not enjoy social activities. I socialize very little.
4 = Extreme. My anxiety has completely disrupted my social activities. All of my relationships have suffered or ended. My family life is extremely strained.

6/09